Provider Services Representative II

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French Camp, CA, US

3 days ago Requisition

Salary Range: $67,900.00 To $92,000.00 Annually

At this time, The Health Plan does not sponsor visa. Candidates must have legal and valid work authorization, Green Card or U.S. citizenship .

This is a hybrid position located at our French Camp office. 2 days onsite; 3 days remote - subject to change based on business needs.

What You Will Be Doing:

Under general supervision, Provider Services Representative II is responsible for establishing and maintaining provider relationships while ensuring the efficient and effective operation and administration of provider contracts. The PSR II travels to provider sites as directed by the Manager or Director.

Essential Functions:

• Conducts regular provider site visits within assigned region, service area or caseload as assigned or in alignment with field work goals.
• Monitors, research, addresses, and resolves complex provider and operational issues that cross departmental lines and may involve senior leadership as necessary; identifies trends; prepares and submits findings and recommendations.
• Establishes and maintains provider relationships; serves as a resource to providers on health plan initiatives and requirements.
• Plans, facilitates and conducts presentations for new provider orientation, regular meetings, seminars, forums and communications with providers and their staff to inform, train, educate, and address service and administrative issues, implement plan changes, ensure compliance with policies and procedures, and other items as necessary.
• Assists in network development activities, including engaging in recruiting efforts with identified providers and identifying contract opportunities.
• Monitors Provider compliance with contractual terms; make recommendations based on findings.
• Documents requested contract changes, Provider grievances, Provider demographic changes, claims or financial issues, and other issues; work with appropriate departments to be addressed.
• Develop materials and other documents in collaboration with stakeholders; distribute and communicate to providers in a timely and effective manner.
• Collaborates, educates and promotes provider participation in quality related programs.
• Support Provider education on quality metrics and care gaps; HEDIS for Medi-Cal and chronic conditions per CMS guidelines for Medicare D-SNP.
• Participates in monitoring of provider Stars Ratings for Medicare D-SNP.
• Educates providers and monitor efforts on model of care for special needs members in Medicare D-SNP.
• Participates in Interdisciplinary Team strategies or discussions and support providers in their monitoring of their scorecard for Medicare D-SNP.
• Supports provider training and discussions related to Risk Adjustment impacting provider incentives for Medicare D-SNP.
• Creates and maintains periodic and ad hoc reports related to provider functions.
• Provides departmental training to new employees based on established guidelines.
• Assists in the development of job aids, workflows, procedures and other documents as directed; implements in a timely and effective manner; makes recommendations for revisions.
• Serves as a subject matter expert for other departments

What You Bring:

Knowledge, Skills,Abilities and Competencies

Required

• Produces work that is accurate and complete.
• Produces the appropriate amount of work.
• Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
• Rebounds from setbacks and adversity when facing difficult situations.
• Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
• Strong understanding of the importance of the relationships between providers and HPSJ/MVHP.
• Basic knowledge of network development and management strategies.
• In-depth knowledge and understanding of the issues affecting providers in HPSJ's/MVHP's service areas.
• Basic knowledge of regulatory guidelines related to commercial or Medi-Cal/Medicaid, or Medicare D-SNP and managed care provider relations.
• In-depth knowledge of provider and/or facility contract and payment structures, and reimbursement practices, including capitation.
• Basic knowledge of medical terminology and coding.
• Interpersonal skills - interact effectively with individuals both inside and outside of HPSJ/MVHP; relates openly and comfortably with diverse groups of people.
• Basic leadership skills, including but not limited to the ability to influence without authority and motivate others.
• Commitment to and ability to facilitate the adoption of HPSJ's/MVHP's strategy, vision, mission and values.
• Strong oral and written communication skills, including the ability to communicate professionally and persuasively, and effectively explain complex information.
• Strong presentation skills, including but not limited to the ability to…